Telehealth Reimbursements Improve, But Access Barriers Still Remain

Patients, not payments, are now the biggest barrier to telehealth adoption among healthcare executives responding to a survey in a new HealthLeaders Intelligence Report.

For years, providers have complained that inadequate reimbursements, particularly from Medicare and Medicaid, have given them little incentive to expand remote care.

But that paradigm shifted during the coronavirus public health emergency, when the Centers for Medicare & Medicaid Services this spring temporarily expanded reimbursements for more than 140 remote services provided by Medicare.

And earlier this month, CMS announced that it has made permanent nine telehealth services and will extend payments for another 59 services beyond the public health emergency in the ongoing effort to expand remote healthcare access in rural America.

Now, 63% of executives responding to our latest Intelligence Report, Telehealth's Road Ahead, identified, "patient ability to use technology" as the biggest barrier for telehealth adoption, compared with 44% of executives who put reimbursement at the top of their lists.

Deanna Larson, CEO of Avera eCARE, a South Dakota–based telehealth network, says technical proficiency should not be a barrier to care. She says health systems must create easy access points for patients, including telephone apps and patient portals.

"It has a lot to do with your selection of the platform being sent out to the general public," she says. "Some people say that it's the older people only, but we definitely have found that ease of use is important for all ages. Think about the apps on your phone. If they're not easy to use or frustrating, you just don't go back."

Even with the CMS action, Ethan Booker, MD, a MedStar Health emergency physician and the medical director of the MedStar Telehealth Innovation Center and MedStar eVisit, says he was surprised by the poll findings on technical barriers.

"It's not entirely our experience. We have had the good fortune of having some very usable platforms," he says. "Certainly, while there are some folks who have struggled, and we support them in all the ways that we can, I wouldn't suggest that patients' difficulty using technology is much of a barrier." 

Telehealth resource allocation

Primary care (73%) and behavioral health (51%) are the two biggest areas where survey respondents are allocating resources. Beyond that, neurology (25%), cardiology (22%), and rehabilitation (22%) lead a half-dozen subspecialties vying for resources.

Larson says she's surprised that providers aren't making an even bigger investment in behavioral health.

"We know that telemedicine is very valuable in the behavioral health space," she says. "It reduces the need to come in for the visit, and sometimes just getting past the social stigma that's associated with meeting in a behavioral health setting that's still out there."

She also questions why survey respondents are allocating relatively few resources for subspecialties such as neurology, cardiology, and ophthalmology.

"It's surprising to me that there isn't more investment for an early identification of an intervention," she says, "bringing them into a higher level of care if identified, and also follow up in all those areas when appropriate for those. It's easy to do in neurology, cardiology, and dermatology."

Booker says primary care is the clear leader in resource allocation in telehealth because the specialty stresses physician-patient communication and "lends itself extremely well to that longitudinal relationship."

"Rather than coming into the office for a handful of visits a year, there's an opportunity to check in more frequently, and perhaps with less intensity to continue to be connected to each other," he says. "It's also true that with value-based payments, population health, ACOs, etc., primary care has moved more fully into that value-based model."

The movement of behavioral health to a telehealth model predates the coronavirus pandemic, Booker says, and includes "a regulatory and reimbursement framework that began to make sense."

"There is an abundance of academic research on quality, safety, and outcomes that demonstrated that behavioral health, psychiatry, cognitive behavioral therapy—many of the core therapies that are delivered by psychiatry—can be very effectively delivered via telehealth," he says.

"There is also a critical access issue in behavioral health that there are not enough professionals to meet the needs. Telehealth has ability to spread out experts to low-density areas and to be efficient in the delivery of care," he says.

As for specialty care, Booker says MedStar Health is developing an infrastructure and a framework for "all kinds of care delivery."

"Primary care and behavioral health are right at the top of our list," he says, "but we think that it's important to build for absolutely everybody in our health system who feels like they could use telehealth to connect with a patient, whether that's fee-for-service evaluation and management, a coded encounter, or some other connection between patient and physician. We have the tools to build for them."

To download the full December 2020 HealthLeaders Intelligence Report, click here.